Community-acquired pneumonia risk factors

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyamvada Singh, M.D. [2]; Philip Marcus, M.D., M.P.H.[3]; Chetan Lokhande, M.B.B.S [4]; Alejandro Lemor, M.D. [5]

Overview

The risk factors for pneumonia include: smoking, age, immunosuppression, exposure to chemicals, underlying lung disease, and exposure to chemicals.

Risk Factors

Risk Factors Related to Specific Causative Pathogens

Condition	Most Common Pathogens
Alcoholism	Streptococcus pneumoniae, oral anaerobes, Klebsiella pneumoniae, Acinetobacter spp, Mycobacterium tuberculosis
COPD	Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp, S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae
Smoking	Haemophilus influenzae, Pseudomonas aeruginosa, Legionella spp, S. pneumoniae, Moraxella catarrhalis, Chlamydophila pneumoniae
Aspiration	Oral anaerobes, Gram-negative enteric bacteria
Lung Abscess	Community-acquired MRSA, M. tuberculosis, oral anaerobes, atypical mycobacteria, endemic fungal infection
Early HIV infection	S. pneumoniae, H. influenzae, M. tuberculosis
Late HIV infection	S. pneumoniae, H. influenzae, M. tuberculosis, Pneumocystis jirovecii, Cryptococcus, Histoplasma, Aspergillus, atypical mycobacteria (especially Mycobacterium kansasii), P.aeruginosa
> 2 weeks of cough with whoop or vomiting	Bordetella pertussis
Structural lung disease	P. aeruginosa, Burkholderia cepacia, S. aureus
IV drug use	S. aureus, anaerobes, M. tuberculosis, S. pneumoniae
Bioterrorism	Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia)
Endobronchial obstruction	S. pneumoniae, anaerobes, H influenzae, S. aureus
Table adapted from IDSA/ATS Guidelines for CAP in Adults

Exposure to Animals

Animals	Most Common Pathogens
Bat or bird droppings	Histoplasma capsulatum
Birds	Chlamydophila psittaci
Rabbits	Francisella tularensis
Farm animals or parturient cats	Coxiella burnetti (Q fever)
Table adapted from IDSA/ATS Guidelines for CAP in Adults

Travel

Condition	Most Common Pathogens
Hotel or cruise ship stay	Legionella spp
Travel to southwestern US	Coccidioides spp, Hantavirus
Travel to southeast or east Asia	Burkholderia pseudomallei, avian influenza, SARS
Table adapted from IDSA/ATS Guidelines for CAP in Adults

Obstruction

• Airway obstruction may cause fluid accumulation in the lungs and result in CAP if the fluids become infected.

• One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung.

• Another cause of obstruction is lung cancer, which can grow into the airways blocking the flow of air.

Lung Disease

• Smoking, and diseases such as emphysema, result in more frequent and severe bouts of CAP.

• In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosis or pulmonary sequestration.

• Hypoxemia

• Pulmonary edema

• Chronic obstructive pulmonary disease (COPD)

• Previous episode of pneumonia or chronic bronchitis

Immune Problems

• People who have immune disorders are more likely to acquire CAP.

• Risk factors for increased mortality from community-acquired pneumonia are: active malignancy, immunosuppression, neurological disease, congestive heart failure, coronary artery disease, and diabetes mellitus.

• People who have AIDS are much more likely to develop CAP. Pneumonia could be the first manifestation of an underlying undiagnosed HIV. It is, thus, recommended by the Center for Disease Control (CDC) that all patients aged 13 to 64 in a medical setting, regardless of known risk factors, be screened for HIV. The American College of Physicians and HIV Medicine Association recommends expanding screening for HIV from age 13 to 75 , .

• Other immune problems range from severe immune deficiencies from childhood, such as Wiskott-Aldrich syndrome, to less severe deficiencies, such as common variable immunodeficiency.

• Elderly people are affected with increased incidence and severity of community-acquired pneumonia. It is the fifth most common cause of death amongst individuals who are greater than 65 years of age, and it is the fourth most common cause of death in individuals who are 85 years or older. The clinical picture in elderly could be subtle and it could be present only as delirium without any fever, cough or sputum. Therefore, a high index of suspicion should be kept in these groups of people.

• Immotile cilia syndrome
• Kartagener's syndrome (ciliary dysfunction, situs inversus, sinusitis, bronchiectasis)
• Young's syndrome (azoospermia, sinusitis, pneumonia)

Other Risk Factors

A few other conditions may lead to pneumonia due to altered pulmonary defense mechanisms.

• Dysphagia due to esophageal lesions and motility problems

• HIV infection (especially for pneumococcal pneumonia)

Drugs

Acid-Suppressing Drugs

• Usage of H2 blockers, proton pump inhibitors, and antacids may increase the pH and, as a result, may increase the risk of pneumonia.

• A similiar study showed increase risk of pneumonia after starting PPI, especially within the first 48 hours. However, the association between PPI and CAP may be cofounded.

Antipsychotic Drugs

• A case control study has shown a significant correlation between the use of antipsychotic drugs and community-acquired pneumonia. A 60 percent increase in the rate of pneumonia can be seen in elderly patients who utilize antipsychotic medications.

• The use of atypical antipsychotics was associated with an increases risk of community-acquired pneumonia.

ACE Inhibitors

• A randomized trial has shown that ACE inhibitors reduce the risk of pneumonia.